Form W-10 - Dependent Care Provider'S Identification And Certification

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Dependent Care Provider’s Identification and Certification
(Rev. October 2016)
Do NOT file Form W-10 with your tax return. Instead, keep it for your records.
Department of the Treasury
Information about Form W-10 and its instructions is at
Internal Revenue Service
Part I
Dependent Care Provider’s Identification (See instructions.)
Name of dependent care provider
Provider’s taxpayer identification number
Address (number, street, and apt. no.)
If the above number is a social security
number, check here
City, state, and ZIP code
Certification and Signature of Dependent Care Provider. Under penalties of perjury, I, as the dependent care provider, certify that my
name, address, and taxpayer identification number shown above are correct.
Dependent care provider’s signature
Part II
Name and Address of Person Requesting Part I Information (See instructions.)
Name, street address, apt. no., city, state, and ZIP code of person requesting information
General Instructions
• If the provider is your household employee and he or she gave
you a properly completed Form W-4, Employee’s Withholding
Section references are to the Internal Revenue Code.
Allowance Certificate, to have income tax withheld, a copy of that
Purpose of form. You must get the information shown in Part I
Form W-4.
from each person or organization that provides care for your child or
If your care provider doesn't comply with your request for one of
other dependent if:
these items, you must still report certain information on your Form
1. You plan to claim a credit for child and dependent care
2441. For details, see the Form 2441 instructions.
expenses on Form 1040 or 1040A, or
Specific Instructions
2. You receive benefits under your employer’s dependent care
Part I
If either 1 or 2 above applies, you must show the correct name,
The individual or organization providing the care completes this
address, and taxpayer identification number (TIN) of each care
provider on Form 2441, Child and Dependent Care Expenses.
Enter the provider’s name, address, and TIN. For individuals and
You may use Form W-10 or any of the other sources listed under
sole proprietors, the TIN is a social security number (SSN). But if the
Due diligence below to get this information from each provider.
provider is a nonresident or resident alien who doesn't have and
Penalty for failure to furnish TIN. TINs are needed to carry out the
isn't eligible to get an SSN, the TIN is an IRS individual taxpayer
Internal Revenue laws of the United States. Section 6109(a)
identification number (ITIN). For other entities, it is the employer
requires a provider of dependent care services to give to you a
identification number (EIN). If the provider is exempt from federal
valid TIN, even if the provider isn't required to file a return. The IRS
income tax as an organization described in section 501(c)(3), see
uses the TIN to identify the provider and verify the accuracy of the
Tax-exempt dependent care provider below.
provider’s return as well as yours.
How to get a TIN. Providers who don't have a TIN should apply for
A care provider who doesn't give you a correct TIN is subject to a
one immediately. To apply for an SSN, get Form SS-5, Application
penalty for each failure unless the failure is due to reasonable cause
for a Social Security Card, from your local Social Security
and not willful neglect. This penalty doesn't apply to an organization
Administration office. To apply for an ITIN, get Form W-7,
described in section 501(c)(3). See Tax-exempt dependent care
Application for IRS Individual Taxpayer Identification Number, from
provider, later.
the IRS. To apply for an EIN, get Form SS-4, Application for
If incorrect information is reported. You won't be allowed the tax
Employer Identification Number, from the IRS.
credit or the exclusion for employer-provided dependent care
Note: An ITIN is for tax use only, and may expire under certain
benefits if:
conditions. It doesn't entitle the individual to social security benefits
• You report an incorrect name, address, or TIN of the provider on
or change his or her employment or immigration status under U.S.
your Form 2441, and
law. For details, see the Form W-7 instructions.
• You can't establish, to the IRS upon its request, that you used
Tax-exempt dependent care provider. A provider who is a tax-
due diligence in trying to get the required information.
exempt organization described in section 501(c)(3) and exempt
under section 501(a) isn't required to supply its TIN. Instead, the
Due diligence. You can show due diligence by getting and keeping
provider must complete the name and address lines and write “tax-
in your records any one of the following.
exempt” in the space for the TIN. Generally, an exempt 501(c)(3)
• A Form W-10 properly completed by the provider.
organization is one organized and operated exclusively for religious,
• A copy of the provider’s social security card or driver’s license
charitable, scientific, testing for public safety, literary, or educational
that includes his or her social security number.
purposes, or for the prevention of cruelty to children or animals.
• A recently printed letterhead or printed invoice that shows the
Part II
provider’s name, address, and TIN.
Complete this part only if you are leaving the form with the
• If the provider is your employer’s dependent care plan, a copy of
dependent care provider to return to you later.
the statement provided by your employer under the plan.
(Rev. 10-2016)
Cat. No. 10437N


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